Checklist template

Infection prevention and control for medical clinics

A ready-to-use checklist with 115 items in 6 sections, covering Hand hygiene, Protective equipment, Cleaning and disinfection, Reprocessing, Isolation practices, Training. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 6 Sections
  • 115 Items
  • 101 Yes / No checks
  • 6 Scored ratings
  • 131 Points

Use this template How audits work

1. Hand hygiene 19 items

  1. An alcohol-based hand rub dispenser is mounted inside or directly outside every exam room Yes / No 1 pt
  2. Hand rub dispensers checked during the visit were working and not empty Yes / No 1 pt
  3. The alcohol content printed on the hand rub in use meets the minimum of the company standard (commonly 60% or 70%) Yes / No 1 pt
  4. Each exam room handwashing sink has liquid soap in a dispenser Yes / No 1 pt
  5. Each exam room handwashing sink has paper towels in a dispenser Yes / No 1 pt
  6. Handwashing sinks are free of stored items, specimens and used instruments Yes / No 1 pt
  7. Refillable soap dispensers are not topped up; cartridges or bottles are replaced Yes / No 1 pt
  8. Hand rub containers are within their expiry date Yes / No 1 pt
  9. Clinicians observed cleaned their hands before touching the patient Yes / No 1 pt
  10. Clinicians observed cleaned their hands after removing gloves Yes / No 1 pt
  11. Staff clean their hands before preparing an injection Yes / No 1 pt
  12. Staff giving direct care have short natural nails with no artificial nails or extenders Yes / No 1 pt
  13. Staff giving direct care wear no rings with stones, bracelets or wrist watches Yes / No 1 pt
  14. Hand rub is available at the check-in counter for patients Yes / No 1 pt
  15. Hand hygiene reminder signs are posted at staff sinks Yes / No 1 pt
  16. Hand lotion supplied to staff is compatible with the hand rub and gloves in use Yes / No 1 pt
  17. Hand hygiene opportunities observed during the visit Number
  18. Opportunities observed where hands were cleaned Number
  19. Hand hygiene practice observed Rating
    • Performed at every opportunity observed 5 pts
    • Missed at some opportunities 3 pts
    • Missed at most opportunities 1 pt

2. Protective equipment 16 items

  1. Exam gloves are stocked in at least three sizes in each exam room Yes / No 1 pt
  2. Procedure masks are stocked in the clinical area Yes / No 1 pt
  3. Fluid-resistant gowns are stocked in the procedure room Yes / No 1 pt
  4. Eye protection or face shields are available where splashes can occur Yes / No 1 pt
  5. Fit-tested respirators are stocked in the sizes and models worn by the staff on duty Yes / No 1 pt
  6. Fit-test records are current for staff who wear a respirator, as required by local regulation Yes / No 1 pt
  7. Gloves are changed between patients Yes / No 1 pt
  8. Gloves are removed before touching keyboards, door handles and phones Yes / No 1 pt
  9. Staff observed removed gown and gloves inside the room before leaving Yes / No 1 pt
  10. Reusable eye protection is disinfected after each use Yes / No 1 pt
  11. Protective equipment is stored in closed boxes or dispensers away from sink splash Yes / No 1 pt
  12. A poster showing the order for putting on and taking off protective equipment is displayed where it is used Yes / No 1 pt
  13. Protective equipment is not worn in the staff break room or at reception Yes / No 1 pt
  14. The clinic holds at least the minimum days of protective equipment stock set by company policy Yes / No 1 pt
  15. Lab coats and scrubs soiled with blood or body fluid are laundered by the clinic's service, not taken home Yes / No 1 pt
  16. Availability and use of protective equipment Rating
    • Stocked and used correctly 5 pts
    • Stocked but use is inconsistent 3 pts
    • Items missing or not used 1 pt

3. Cleaning and disinfection 26 items

  1. The disinfectant used on clinical surfaces is a product registered for healthcare use Yes / No 1 pt
  2. The contact time of the surface disinfectant is known by 2 staff members asked Yes / No 1 pt
  3. Disinfectant wipe canisters are kept closed and are within their expiry date Yes / No 1 pt
  4. The exam table is disinfected between patients Yes / No 1 pt
  5. Multi-dose vials are dated when opened and kept away from the immediate patient treatment area Yes / No 1 pt
  6. Blood pressure cuffs are wiped with disinfectant between patients Yes / No 1 pt
  7. Stethoscope diaphragms are wiped with disinfectant between patients Yes / No 1 pt
  8. Glucose meters are disinfected after every patient with a product approved by the meter manufacturer Yes / No 1 pt
  9. Otoscope specula are single-use or are reprocessed after each patient Yes / No 1 pt
  10. High-touch surfaces in exam rooms (door handles, light switches, chair arms) are disinfected at least daily Yes / No 1 pt
  11. A written cleaning schedule names who cleans what in the clinical area Yes / No 1 pt
  12. The cleaning schedule is signed off for each of the last 7 clinic days Yes / No 1 pt
  13. A blood and body fluid spill kit is available in the clinical area Yes / No 1 pt
  14. Staff asked could describe how to clean a blood spill Yes / No 1 pt
  15. Ultrasound gel is dispensed from single-use packets or from bottles that are never topped up Yes / No 1 pt
  16. The product used on waiting room toys is one the label allows for items children put in their mouth, or toys are rinsed after disinfection Yes / No 1 pt
  17. Staff asked could say how a visibly soiled privacy curtain gets changed the same day Yes / No 1 pt
  18. Mop heads and cleaning cloths are laundered or replaced daily Yes / No 1 pt
  19. Cleaning carts keep clean cloths separate from used ones Yes / No 1 pt
  20. Diluted disinfectant bottles are labeled with the product name and the date mixed Yes / No 1 pt
  21. Tablets, clipboards and pens handed to patients are disinfected between patients Yes / No 1 pt
  22. Clean linen is stored in a closed cupboard or covered cart Yes / No 1 pt
  23. Used linen is bagged at the point of use Yes / No 1 pt
  24. Vaccine and medication refrigerators hold no food or drink Yes / No 1 pt
  25. Date of the last deep clean of the clinical area Date
  26. Cleanliness of exam and procedure rooms Rating
    • Visibly clean with records complete 5 pts
    • Clean with gaps in records 3 pts
    • Visible soil or dust on clinical surfaces 1 pt

4. Reprocessing 23 items

  1. Reusable instruments are reprocessed Choice
    • On site
    • By an outside service
    • Not applicable, single-use only
  2. Used instruments are carried to the reprocessing area in a closed, labeled container Yes / No 1 pt
  3. The reprocessing area has a one-way flow from dirty to clean Yes / No 1 pt
  4. Dirty and clean work surfaces are physically separated Yes / No 1 pt
  5. Instruments are cleaned with an enzymatic detergent before sterilization Yes / No 1 pt
  6. Enzymatic detergent is diluted according to the label, with a measuring device at the sink Yes / No 1 pt
  7. The ultrasonic cleaner solution is changed at least daily Yes / No 1 pt
  8. Hinged instruments are opened before packaging Yes / No 1 pt
  9. Each pack contains a chemical indicator inside Yes / No 1 pt
  10. Each pack is labeled with the sterilizer, the load number and the date Yes / No 1 pt
  11. The sterilizer log records time, temperature and pressure for every load Yes / No 1 pt
  12. A biological indicator test is run on each sterilizer at the frequency set by company policy (weekly at the least) Yes / No 1 pt
  13. Date of the last biological indicator test Date
  14. Results of biological indicator tests for the last 3 months are on file Yes / No 1 pt
  15. Staff asked could explain what to do with a load after a failed indicator Yes / No 1 pt
  16. Sterile packs are stored in a closed cabinet away from the sink Yes / No 1 pt
  17. Sterile packs sampled were dry and intact Yes / No 1 pt
  18. Single-use devices are not reprocessed Yes / No 1 pt
  19. The high-level disinfectant for semi-critical devices (vaginal probes, endoscopes) is tested with a test strip each day of use Yes / No 1 pt
  20. High-level disinfectant test strip results are recorded Yes / No 1 pt
  21. Sterilizer preventive maintenance is up to date according to the service sticker or record Yes / No 1 pt
  22. Staff who reprocess wear heavy-duty gloves, a gown and face protection at the dirty sink Yes / No 1 pt
  23. Reprocessing practice and records Rating
    • Complete and correct 5 pts
    • Minor gaps in records 3 pts
    • Steps missing or no records 1 pt

5. Isolation practices 15 items

  1. Signs at the entrance ask patients with fever, cough or rash to tell reception Yes / No 1 pt
  2. Masks are offered at reception to patients with a cough Yes / No 1 pt
  3. Tissues are available in the waiting room Yes / No 1 pt
  4. A no-touch waste bin is available in the waiting room Yes / No 1 pt
  5. Reception staff ask screening questions about fever, rash and recent travel when required by the company protocol Yes / No 1 pt
  6. Patients with a suspected airborne infection (measles, chickenpox, tuberculosis) are taken straight to a room with the door closed Yes / No 1 pt
  7. A room is designated for patients who need isolation Yes / No 1 pt
  8. Signs for contact, droplet and airborne precautions are available to post on the room door Yes / No 1 pt
  9. The room is left empty after a suspected airborne case for the time set by company protocol Yes / No 1 pt
  10. Protective equipment for the precaution in place is available at the door of the isolation room Yes / No 1 pt
  11. Staff asked know how to report a notifiable disease to public health as required by local regulation Yes / No 1 pt
  12. Waiting room seating allows symptomatic patients to sit apart from others Yes / No 1 pt
  13. Dedicated or disposable equipment is used for patients on contact precautions Yes / No 1 pt
  14. The cleaning of a room used for a patient on precautions is recorded Yes / No 1 pt
  15. Readiness to separate a potentially infectious patient Rating
    • Room, signs and equipment ready 5 pts
    • Possible with delay 3 pts
    • No workable arrangement 1 pt

6. Training 16 items

  1. All clinical staff completed infection prevention training in the last 12 months Yes / No 1 pt
  2. New hires complete infection prevention training before working with patients Yes / No 1 pt
  3. Staff who reprocess instruments have documented competency for the sterilizer in use Yes / No 1 pt
  4. Cleaning contractors received instruction on the clinic's disinfectant and contact time Yes / No 1 pt
  5. A named person is responsible for infection prevention at the clinic Yes / No 1 pt
  6. Name of the person responsible for infection prevention Short text
  7. Hand hygiene observations are recorded at the frequency set by company policy Yes / No 1 pt
  8. Results of hand hygiene observations are shared with staff Yes / No 1 pt
  9. Staff immunization or immunity records are on file as required by company policy Yes / No 1 pt
  10. Staff asked know to stay off work when they have fever, vomiting or diarrhea Yes / No 1 pt
  11. Written infection prevention procedures are available at the clinic Yes / No 1 pt
  12. Safe injection practice (one needle, one syringe, one use) is covered in annual training Yes / No 1 pt
  13. Corrective actions from the previous infection prevention review have been completed Yes / No 1 pt
  14. Name of the clinic manager Short text
  15. Overall infection prevention and control Rating
    • Hand hygiene, cleaning and reprocessing done and recorded 5 pts
    • Practices sound, with gaps in supplies or records 3 pts
    • Missed hand hygiene, visible soil or reprocessing steps skipped 1 pt
  16. Corrective actions required Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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